'We all have the same right to have health services': a case study of Namati's legal empowerment program in Mozambique.

BACKGROUND: Legal empowerment and social accountability are two strategies that are increasingly used to address gaps in healthcare in low- and middle-income countries, including failure to provide services that should be available and poor clinical and interpersonal quality of care. This paper is an explanatory case study of a legal empowerment effort that employs community paralegals and trains Village Health Committees (VHCs) in Mozambique. The research objective was to explore how community paralegals solved cases, the impact paralegals had on health services, and how their work affected the relationship between the community and the health sector at the local level. METHODS: The case study had two components: (1) a retrospective review of 24 cases of patient/community grievances about the health system, and (2) qualitative investigation of the program and program context. The case reviews were accomplished by conducting structured in-depth interviews (IDIs) with those directly involved in the case. The qualitative investigation entailed semi-structured Key Informant Interviews (KIIs) with district, provincial, and national health managers and Namati staff. In addition, focus group discussions (FGDs) were held with Health Advocates and VHC members. RESULTS: Case resolution conferred a sense of empowerment to clients, brought immediate, concrete improvements in health service quality at the health facilities concerned, and seemingly instigated a virtuous circle of rights-claiming. The program also engendered incipient improvements in relations between clients and the health system. We identified three key mechanisms underlying case resolution, including: bolstered administrative capacity within the health sector, reduced transaction and political costs for health providers, and provider fear of administrative sanction. CONCLUSIONS: This study contributes to the limited literature regarding the mechanisms of legal empowerment case resolution in health systems and the impact of hybrid legal empowerment and social accountability approaches. Future research might assess the sustainability of case resolution; how governance at central, provincial, and district level is affected by similar programs; and to what extent the mix of different cases addressed by legal empowerment influences the success of the program.

Cochlear Implants in Congenitally Deaf Children: A Discussion Built on Rights-Based Arguments.

The author discusses rights-based arguments for and against cochlear implants in congenitally deaf children and analyzes whether CIs should be required by law or left to parental discretion. Positions for and against CIs are analyzed in light of two rights-based arguments: Griffin's theory on personhood as a solution to a conflict of rights and his theory on quality of life as a solution to a conflict between rights and welfare (Griffin, 2008). The question of whether CIs should be required by law is then discussed in light of Nickel's theories on the justification of specific rights and on the avoidance of conflicts (Nickel, 2007). In this discussion, the author's aim is not to propose definitive answers, but to apply philosophical theories to the debate and introduce tools for analyzing arguments for and against CIs in children and for regulating cochlear implantation.

Examining the impact of occupational health and safety vulnerability on injury claim reporting in three Canadian provinces.

INTRODUCTION: The workers' compensation system covers wages and health care costs associated with work-related injuries or illnesses. We explore if dimensions of occupational health and safety vulnerability are associated with differences in reporting work-related injuries to workers' compensation boards (WCBs). METHODS: We examined data from adults reporting physical workplace injuries requiring time off or health care. We explored relationships between exposure to nine hazards, risk from inadequate policies and procedures, inadequate occupational health and safety (OHS) awareness, inadequate empowerment, and reporting to provincial WCBs. Odds ratios (ORs) were calculated to assess risk from dimensions of workplace vulnerability for not reporting an injury to WCBs. RESULTS: Of 326 participants, 64% did not report injuries to WCBs. Reporting was higher among those with hazardous workplace exposures compared to those without (40% vs 22%, P = .01), lower among those with inadequate policy and procedures and inadequate awareness protections. Inadequate OHS awareness protection was related to not reporting to WCBs in logistic regression models. Women, those working part-time, workers in education, health, and public administration, and non-unionized workers were less likely to report injuries (nonsignificant), while workers with postgraduate educations were significantly less likely to report an injury compared to referent (OR = 3.89, 95% CI: 1.57-9.62). CONCLUSION: A general lack of knowledge about OHS rights and responsibilities was associated with low levels of reporting. This suggests there is a knowledge deficit among some workers, possibly amenable to joint efforts to increase rights and responsibilities related to OHS with the dissemination of information about rights to workers' compensation.

Sobreviver nas ruas: percursos de resistência à negação do direito à saúde / Sobrevivir en las calles: resistencias a la negación del derecho a la salud / Surviving on the streets: paths of resistance to the denial of health rights

RESUMO. Contextos de exclusão conformam ciclos de marginalização de grupos populacionais, como a população em situação de rua (PSR). Nesse contexto violações de direitos humanos são recorrentes, em especial a dificuldade de acesso à saúde. A efetivação das políticas para a PSR nas cidades brasileiras ainda é escassa, por sua restrição a cidades de médio e grande porte e ao parco investimento público. Dessa forma, o estudo tem por objetivo investigar os percursos de cuidado à saúde da PSR em um município de pequeno porte. Foram realizadas observações de campo e entrevistas semiestruturadas para identificação e compreensão dos recursos acionados nas trajetórias de cuidado à saúde, que foram analisadas a partir da análise de conteúdo temática. Ressaltaram-se as diversas estratégias desenvolvidas pelo público diante da negação do direito à saúde e ao autocuidado. Destacam-se entre os resultados a precariedade de ofertas ao cuidado da saúde da mulher, a restrição do cuidado em saúde ao uso de substâncias psicoativas, de cunho medicalizante e centrado no paradigma da abstinência. Observou-se a importância da moradia para o cuidado integral, e das redes sociais e comunitárias como forma de restabelecimento da saúde nas ruas.

RESUMEN. Los contextos de exclusión conforman ciclos de marginación de grupos poblacionales, como la población en situación de calle (PSC). En este contexto, violaciones de derechos humanos son recurrentes, en especial la dificultad de acceso a la salud. La efectividad de las políticas para la PSC en las ciudades brasileñas sigue siendo escasa, por su restricción a ciudades de mediano y gran porte y a la poca inversión pública. Así, el estudio buscó investigar los recorridos de cuidado a la salud de la PSC en una ciudad de pequeño porte. Se realizaron observaciones de campo y entrevistas semiestructuradas para identificación y comprensión de los recursos accionados en las trayectorias de cuidado de la salud, que fueron analizadas a partir del análisis de contenido temático. Se resaltan las diversas estrategias desarrolladas por este público como forma de resistencia a la negación del derecho a la salud y autocuidado. Se destacan la precariedad de ofertas al cuidado de la salud de la mujer, la restricción del cuidado en salud al uso de sustancias psicoactivas, de cuño de medicalización y centrado en el paradigma de la abstinencia. Se observaron la importancia de la vivienda para el cuidado integral, y de las redes sociales y comunitarias como forma de restablecimiento de la salud en las calles.

ABSTRACT. Exclusion contexts constitute cycles of marginalization of population groups, such as the homeless people (HP). In this context, human rights violations are recurrent, especially related to the difficulty of access to health services. The effectiveness of the policies for HP in Brazilian cities is still scarce, due to its restriction to medium and large cities and the limited public investment. Thus, the study sought to investigate HP health care paths in a small city. Field observations and semi-structured interviews were carried out to identify and understand the resources used in health care trajectories, which were analyzed based on thematic content analysis. Several strategies developed by the public in the face of the denial to the health rights and self-care are highlighted. Among the results, the precariousness of offers to women's health care, the restriction of health care to the use of psychoactive substances, of medicalizing nature and centered on the abstinence paradigm were stood out. It was observed the importance of housing for comprehensive care, and social and community networks as a way of restoring health on the streets.

The Right to Accessible and Acceptable Healthcare Services. Negotiating Rules and Solutions With Members of Ethnocultural Minorities.

The right to health implies, among other things, that individuals and communities must be allowed to have a voice in decisions concerning the definition of their well-being. The article argues for a more active participation of ethnocultural minorities in healthcare decisions and highlights the relevance of strategies aimed at creating a bottom-up engagement of people and groups, as well as of measures aimed at a broader organizational flexibility, in order to meet migrants' and minorities' needs. Finally, the article clarifies that these strategies are not simply the outcome of a welcoming attitude of the Western healthcare system but may be interpreted as a specific duty resulting from the notion of "particularly vulnerable groups," as formulated by the ECtHR in its case law: when vulnerable groups are at stake, every decision about state actions and rules regarding healthcare should start from an a consideration of the specific conditions and needs of people belonging to vulnerable minority groups.